Approaches to Therapy: A Practical Guide

When it comes to therapy, finding the right approach is as important (almost) as finding the right therapist. Each therapist is trained to follow a particular way of working. We call these approaches the therapists' orientation.

A therapist's orientation (or orientation for short) refers to the underlying philosophy and theory that guides how the therapist understands people and approaches their challenges. You could think of this as a compass that orientates the therapist to where they are and where they are headed. For example, a medical orientation encourages the practitioner to identify symptoms (e.g. depressed mood) that diagnose an underlying disease (e.g. depression) which can be medically treated (e.g. antidepressants). In contrast, a psychodynamic approach might be understanding the psychological dynamics.

No one orientation is better, and there is often considerable overlap between them despite their different language to describe similar things. This does not mean that they are all the same or equally appropriate in all instances since each emphasises different goals. For example, short-term, symptom-focused approaches help you quickly address target symptoms (e.g. a phobia), while longer-term, intensive methods aim for lasting, broader change.

We cover therapies from the most established orientations below; there are many more, but these are the most widely practised. If you notice an important one missing and would like to submit an explanatory paragraph in line with the others, we would happily consider including it.

Cognitive Behavioural Therapy (CBT)

Cognitive behavioural therapy (CBT) offers a practical and measurable approach to therapy. It starts from the premise that what we believe, the way we think and the behaviours we have learned perpetuate (if not cause) the emotional difficulties we experience (e.g. you might feel depressed because you keep thinking you are bad). Thus, changing how you think and act can change how you feel.

CBT helps by providing a combination of education, structured interventions and directions that target specific symptoms. You might be taught how to identify your thoughts and mood and be asked to apply the principles via homework, e.g. keep a thought diary. In the case of phobias, a person might be asked to face their fears in a planned and graded way while practising relaxation techniques.

This approach is concrete, hands-on, and appeals to one's common sense. You don't need decades of study to understand its core principles. It is easily written into manuals, and its definable and measurable goals provide helpful direction. These features also make it easy to research, and many studies confirm CBT effectively and efficiently reduces specific symptoms.

Recently, CBT has included mindfulness and acceptance into its paradigm. Some practitioners see this as an evolution, shifting CBT's emphasis from reducing and managing dysfunctional thinking styles towards embracing the value of acceptance and moving forward or letting go. Mindfulness and Dialectical Behavioural Therapy are two examples.

CBT is an excellent first port of call, especially in defined instances of phobia, OCD, depression, social anxiety and panic. It is less valuable when aims are less circumscribed, e.g. wanting to develop maturity and depth or seeking insight into interpersonal or self-defeating patterns,

Highlights:

Concrete and measurable.

Appeals to common sense.

Research-backed effectiveness.

Ideal for specific issues like phobias, OCD, and anxieties.

Psychoanalysis

Psychoanalysis is a sophisticated body of theory and practice that has evolved in different directions over more than a century. The theory is dense, complicated and intimidating, but it's relatively straightforward once you grasp its core concepts. Some of its grounding ideas include that we don't always know or understand our motives or the meaning of our actions, we try to avoid painful feelings, our wishes frequently conflict, and we can confuse parts of our feelings, fantasies, and thoughts with reality.

Psychoanalysis proper is carried out several times per week over several years. This technique's cornerstone is free association (all that comes to mind without censorship). The analyst and patient listen to the patient's associations with care and curiosity. Both parties then gradually develop a profound understanding of the patient, how they became who they are, and how they contribute to their troubles.

This practice's long-term and unstructured nature renders it challenging to research. Fortunately, the number of high-quality research trials supporting psychotherapies based on the principles of psychoanalysis is mounting.

Conducting psychoanalysis is an advanced skill. Training as a psychoanalyst involves undergoing a complete personal analysis (usually four times weekly for years), performing closely supervised work with patients, and completing a demanding theoretical program. It is impractical to incorporate more than a basic introduction when training psychologists, psychiatrists, social workers, etc. For this reason, question what you read online about psychoanalysis.

Psychoanalysis is a good choice, particularly if you have tried other routes, are struggling with long-lasting difficulties, are naturally drawn to this way of thinking, or are a psychotherapist wanting to deepen your work with your patients.

Highlights:

• Intensive and long-term.
  
• In-depth exploration of unconscious motives.
  
• Profound understanding of self.
  
• Demands commitment and patience.

Psychodynamic Psychotherapy

Professionals from various backgrounds may hold a psychodynamic orientation, including many psychologists, psychiatrists, social workers, occupational therapists and even nurses. Psychodynamic psychotherapy (sometimes called insight-oriented therapy) applies the same theories as psychoanalysis but in a distilled, less intensive and more pragmatic way. Therapists working from this perspective tend to talk more than psychoanalysts. They also guide their patients towards recognising their defences, conflicts, interpersonal patterns, and how their past experiences influence the present.

The relationship with the therapist in the 'here and now is frequently used as a valuable source of information and taken as a site where the patient's (and therapist's) patterns play out live. Witnessing yourself repeating the same patterns in therapy that brought you to therapy or noticing how you start to see your therapist in the same way that you tend to see other influential people is a compelling way to discover your contribution to things.

Psychodynamic psychotherapy is beneficial for interpersonal difficulties and working on how you relate to yourself and your emotions. A successful, long-term psychodynamic therapy should produce internal changes that develop long after the therapy ends. This approach is an excellent first port of call for a broad range of difficulties, especially if you are open to a longer-term process.

Highlights:

• Distilled, pragmatic version of psychoanalysis.
  
• Focus on interpersonal dynamics.
  
• Real-time exploration of relationships.
  
• Long-lasting internal changes.
  

Narrative Therapy

The narrative therapy method works with how a person tells their life story. People are thought to hold a narrative of their lives that foregrounds specific details at the expense of others, i.e. it's one version of a life story that potentially keeps you stuck by leaving out details that might change things significantly. A narrative therapist might help their patient find alternative ways to see their lives less saturated with difficulties and impossibilities and more open to potential and success.

Narrative therapists view problems as separate from people. As such, they work with clients to help them separate themselves from their problems and to develop tools and resources to address the issues that they are experiencing. A narrative therapist considers the client the ultimate expert on their life and views the therapist's role as more of a curious, investigative reporter assisting the client in making discoveries through different interviewing questions.

Highlights:

• Focus on personal storytelling.
  
• Problems are viewed as separate from identity.
  
• Empowers you to rewrite your narrative.
  
• Unearths overlooked possibilities.
  

Humanistic Existentialism

A humanistic or existential orientation underpins a wide range of therapies. These approaches foreground human experience rather than dynamics, symptoms or diagnostic categories. The difficulties people present are taken as an expression of their inability to live in an authentic, meaningful and self-guided way. Therapy guides the person towards healthy and meaningful ways, self-awareness, and acceptance of personal responsibility and free will. Although humanistic and existential approaches are often grouped, they emphasise different things.

Humanistic approaches view people as inherently good and innately capable of directing their lives and relationships to themselves and others in healthy and meaningful ways. People fail to do this only because they hold conscious assumptions that inhibit them from acting as their true selves. Therapy overcomes these blocks to living in an actualised way by promoting growth rather than cure.

Existentialism holds that the individual is a conscious, free, self-directed actor, but it emphasises the need to find meaning in our lives. The problems we face stem from the challenge of living a meaningful life given the context of essential loneliness, isolation, despair, and death inevitability. The solution is to live authentically and creatively while accepting we are each responsible for finding meaning in our lives, no matter what circumstances we face.

Highlights:

• Focus on personal growth and authenticity.
  
• Emphasis on self-understanding and self-awareness.
  
• Encourages acceptance and personal responsibility.
  
• Nurtures inherent goodness and potential.
  

In conclusion, therapy is a personal journey, and finding the right approach is a big part. Each approach offers its tools, and there's no one-size-fits-all. You should choose what feels right for you, whether it's the practicality of Cognitive Behavioral Therapy, the depth of Psychoanalysis, or something else. With the right approach and a good therapist, you can navigate through your thoughts and feelings and start feeling better.